New Jersey Department of Health

Vaccines for Children (NJVFC) Program

P.O. Box 369

Trenton, NJ 08625-0369

Phone: (609) 826-4862 Fax: (609) 826-4868

INSTRUCTIONS: Email completed New Provider Enrollment for Adult Site and New Provider Agreement for Adult Site to: VFC@doh.nj.gov.	NEW PROVIDER ENROLLMENT

FOR ADULT SITE
Today’s Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __
PROVIDER INFORMATION
Office Name:
Office Medicaid Number:	Office NPI Number:	Office Tax ID:
Provider Type:
Private Facilities:	Not for Profit Clinic (Proof of not for profit status must be sent with this enrollment.)
Public Facilities:	Public Health Department Federally Qualified Health Center
Vaccines Offered (Select only one box):
All ACIP Recommended Vaccines for Adults
Offers Select Vaccines (This option is only available for facilities designated as “Specialty Providers” by the 317 Program.)
A “Specialty Provider” is defined as a provider that only serves (1) a defined population due to the practice specialty (e.g., OB/GYN, STD clinic, family planning) or (2) a specific age group within the general population of adults ages 19+. Local health departments are not considered specialty providers. The 317 Program has the authority to designate 317 providers as specialty providers.
Select Vaccines Offered by Specialty Provider:
Hepatitis A/B	Meningococcal Conjugate	TD
HPV	MMR	Tdap
Influenza	Pneumococcal Conjugate	Varicella
Men B	Pneumococcal Polysaccharide	Zoster
Other (specify):
Vaccine Delivery Address
Address 1:	Address 2:
City:	State:	NJ	Zip:
County:	Municipality:
Phone:	( )	Ext.	Fax:	( )
Email:
LICENSED MEDICAL PROVIDERS
The Medical Director signing this agreement must be authorized to administer adult vaccines under state law. The Medical Director will be held accountable for 317-Funded Adult Program compliance by the entire organization with all items stated in the Provider Agreement for adult sites.
1. Medical Director	Title:	MD DO	Date of Birth:
Last Name:	First Name:	Middle Name:
NPI No.:	Medical License No.:	Medicaid No.:
2. Licensed Medical Provider	Title:	MD DO PA NP	Date of Birth:
Last Name:	First Name:	Middle Name:
NPI No.:	Medical License No.:	Medicaid No.:
LICENSED MEDICAL PROVIDERS, CONTINUED
3. Licensed Medical Provider	Title:	MD DO PA NP	Date of Birth:
Last Name:	First Name:	Middle Name:
NPI No.:	Medical License No.:	Medicaid No.:
4. Licensed Medical Provider	Title:	MD DO PA NP	Date of Birth:
Last Name:	First Name:	Middle Name:
NPI No.:	Medical License No.:	Medicaid No.:
ASSOCIATED ADDITIONAL MEDICAL OFFICES

(Complete this section only if there are other offices in the practice. If none, go to next section.)
1. Medical Office Name:	VFC Pin:
Street 1:	Street 2:
City:	State:	NJ	Zip:
County:	Municipality:
Phone:	( )	Ext.	Fax:	( )
2. Medical Office Name:	VFC Pin:
Street 1:	Street 2:
City:	State:	NJ	Zip:
County:	Municipality:
Phone:	( )	Ext.	Fax:	( )
ADULT SITE CONTACTS
Two designated on-site and fully trained staff responsible for all vaccine management activities within the practice.
Primary Vaccine Coordinator:
Last Name:	First Name:	Middle Name:
Email:	Phone:	Ext.
Backup Vaccine Coordinator:
Last Name:	First Name:	Middle Name:
Email:	Phone:	Ext.
VACCINE DELIVERY HOURS

(Hours when vaccine shipments can be delivered. Exclude lunch hours if office is closed. Note: No deliveries are made on Mondays.)
Tuesday Wednesday Thursday Friday
From (hh:mm):	:	To (hh:mm):	:	AND
From (hh:mm):	:	To (hh:mm):	:
Tuesday Wednesday Thursday Friday
From (hh:mm):	:	To (hh:mm):	:	AND
From (hh:mm):	:	To (hh:mm):	:
Tuesday Wednesday Thursday Friday
From (hh:mm):	:	To (hh:mm):	:	AND
From (hh:mm):	:	To (hh:mm):	:
Special Delivery Instructions:
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY (NIST) THERMOMETERS

(Enter only one Certification Number for dual probe thermometer Certificates.)
Thermometers:
1. Type:	Data Logger

Digital Min/Max Thermometer	Certification or Serial Number:	NIST Certification Expiration Date:
2. Type:	Data Logger

Digital Min/Max Thermometer	Certification or Serial Number:	NIST Certification Expiration Date:
3. Type:	Data Logger

Digital Min/Max Thermometer	Certification or Serial Number:	NIST Certification Expiration Date:
4. Type:	Data Logger

Digital Min/Max Thermometer	Certification or Serial Number:	NIST Certification Expiration Date:
Back-Up Thermometer (Required):
1. Type:	Data Logger

Digital Min/Max Thermometer	Certification or Serial Number:	NIST Certification Expiration Date:
PROVIDER POPULATION:
Provider population based on patients seen during the previous 12 months. Report the number of adults who received vaccinations at your facility, by age group. Only count an adult once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many adults received 317-funded vaccine, by category, and how many received non-317 vaccine.
Number of Adults Who Received Vaccine by Age Category
317 Vaccine Eligibility Categories
19-29 years old
30-39 years old
40-59 years old
60+ years old
No Health Insurance
Underinsured 1
Non-317 Vaccine Eligibility Category
19-29 years old
30-39 years old
40-59 years old
60+ years old
Health Insurance Pays Some/All Vaccine Cost
1	Underinsured includes adults with health insurance that does not include vaccines or only covers specific vaccine types. Adults are only eligible for vaccines that are not covered by insurance.
TYPE OF DATA USED TO DETERMINE PROVIDER POPULATION (Choose ALL that apply):
Benchmarking	Doses Administered
Medicaid Claims Data	Provider Encounter Data
NJIIS	Billing System
Other (must describe):
The Medical Director signing this agreement must be authorized to administer adult vaccines under state law. The Medical Director will be held accountable for 317-Funded Adult Program compliance by the entire organization with all items stated in the Provider Agreement for adult sites.
Print Name of Medical Director:
Signature of Medical Director:
Date:
FOR STATE USE ONLY
Date Certified for NJVFC	Staff Name	PIN Number
Federal HHS OIG Search Done	Yes

No	NJ Consumer Affairs OIG Search Done	Yes

No	Address Checked on USPS Site	Yes

No	Correction made to conform to USPS Address	Yes

No	Checked Not for Profit Status	Yes

No
Document clarification of HHS OIG an NJ Division of Consumer Affairs issues here:

NEW PROVIDER ENROLLMENT FOR ADULT SITE

(Continued)

IMM-18

JUL 16	Page 4 of 4 Pages.

JUL 16	Page 1 of 4 Pages.

IMM-18, Vaccines for Children Program, Provider Profile-Adolescents/adults

IMM-18, VFC, vaccine-preventable diseases program, immunization, vaccine, PROVIDER, PROFILE, adult, adolescent

EWhite

2016-02-17

NJDOH